Background: For patients with cluster B personality disorders there is no consensus regarding the optimal treatment setting. The aim of this study was to compare the effectiveness of different psychotherapeutic settings for patients with cluster B personality disorders, i.e. outpatient, day hospital, and inpatient treatment. Methods: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 207 patients with a DSM-IV-TR axis II cluster B diagnosis. Patients were assigned to 3 different settings of psychotherapeutic treatment and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. Results: Patients in all 3 settings improved significantly in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life 18 months after baseline. The inpatient group showed the largest improvements. The comparison of outpatient and inpatient treatment regarding psychiatric symptoms showed a marginally significant result (p = 0.057) in favour of inpatient treatment. Conclusions: Patients with cluster B personality disorders improved in all investigated treatment settings, with a trend towards larger improvements of psychiatric symptoms in the inpatient setting compared to the outpatient setting. Specialised inpatient treatment should be considered as a valuable treatment option for cluster B personality disorders, both in research and in clinical practice.

Keywords:
Psychotherapy, Treatment effectiveness, Histrionic personality disorder, Narcissistic personality disorder, Personality disorders, Treatment outcome, Antisocial personality disorder, Borderline personality disorder
1.
Torgersen S, Kringlen E, Cramer V: The prevalence of personality disorders in a community sample. Arch Gen Psychiatry 2001;58:590–596.
2.
Samuels J, Eaton WW, Bienvenu Ili OJ, Brown CH, Costa PT Jr, Nestadt G: Prevalence and correlates of personality disorders in a community sample. Br J Psychiatry 2002;180:536.
3.
Zimmerman M, Rothschild L, Chelminski I: The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 2005;162:1911–1918.
4.
Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M: Borderline personality disorder. Lancet 2004;364:453–461.
5.
Nestadt G, Romanoski AJ, Chahal R, Merchant A, Folstein MF, Gruenberg EM, McHugh PR: An epidemiological study of histrionic personality disorder. Psychol Med 1990;20:413–422.
6.
Ogrodniczuk JS, Piper WE, Joyce AS, Steinberg PI, Duggal S: Interpersonal problems associated with narcissism among psychiatric outpatients. J Psychiatr Res 2009;43:837–842.
7.
Duggan C: A treatment guideline for people with antisocial personality disorder: overcoming attitudinal barriers and evidential limitations. Crim Behav Ment Health 2009;19:219–223.
8.
Coid J, Yang M, Tyrer P, Roberts A, Ullrich S: Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry 2006;188:423–431.
9.
Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT, Zanarini MC, Oldham JM, Gunderson JG: Treatment utilization by patients with personality disorders. Am J Psychiatry 2001;158:295–302.
10.
Skodol AE, Gunderson JG, Shea MT, McGlashan TH, Morey LC, Sanislow CA, Bender DS, Grilo CM, Zanarini MC, Yen S, Pagano ME, Stout RL: The collaborative longitudinal personality disorders study (CLPS): overview and implications. J Pers Disord 2005;19:487–504.
11.
Cramer V, Torgersen S, Kringlen E: Personality disorders and quality of life. A population study. Compr Psychiatry 2006;47:178–184.
12.
van Asselt AD, Dirksen CD, Arntz A, Severens JL: The cost of borderline personality disorder: societal cost of illness in BPD-patients. Eur Psychiatry 2007;22:354–361.
13.
Soeteman DI, Hakkaart-van Roijen L, Verheul R, Busschbach JJV: The economic burden of personality disorders in mental health care. J Clin Psychiatry 2008;69:259–265.
14.
de Groot ER, Verheul R, Trijsburg RW: An integrative perspective on psychotherapeutic treatments for borderline personality disorder. J Pers Disord 2008;22:332–352.
15.
Zanarini MC: Psychotherapy of borderline personality disorder. Acta Psychiatr Scand 2009;120:373–377.
16.
Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford Press, 1993.
17.
Bateman AW, Fonagy P: Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment. Oxford, Oxford University Press, 2004.
18.
Young JE, Klosko JS, Weishaar ME: Schema Therapy: A Practitioner’s Guide. New York, Guilford Press, 2003.
19.
Yeomans FE, Clarkin JF, Kernberg OF: A Primer of Transference-Focused Psychotherapy for the Borderline Patient. Lanham, Jason Aronson Inc, 2002.
20.
Bateman A, Fonagy P: Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 1999;156:1563–1569.
21.
Bateman A, Fonagy P: Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 2001;158:36–42.
22.
Bateman A, Fonagy P: Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009;166:1355–1364.
23.
Turner RM: Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder. Cogn Behav Pract 2000;7:413–419.
24.
Koons CR, Robins CJ, Tweed JL, Lynch TR, Gonzalez AM, Morse JQ, Bishop GK, Butterfield MI: Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behav Ther 2001;32:371–390.
25.
Teusch L, Bohme H, Finke J, Gastpar M: Effects of client-centered psychotherapy for personality disorders alone and in combination with psychopharmacological treatment: an empirical follow-up study. Psychother Psychosom 2001;70:328–336.
26.
Davidson K, Norrie J, Tyrer P, Gumley A, Tata P, Murray H, Palmer S: The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. J Pers Disord 2006;20:450–465.
27.
Farrell JM, Shaw IA, Webber MA: A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: a randomized controlled trial. J Behav Ther Exp Psychiatry 2009;40:317–328.
28.
Soler J, Pascual JC, Tiana T, Cebria A, Barrachina J, Campins MJ, Gich I, Alvarez E, Perez V: Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: a 3-month randomised controlled clinical trial. Behav Res Ther 2009;47:353–358.
29.
McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL: A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry 2009;166:1365–1374.
30.
Giesen-Bloo J, Van Dyck R, Spinhoven P, Van Tilburg W, Dirksen C, Van Asselt T, Kremers I, Nadort M, Arntz A: Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry 2006;63:649–658.
31.
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF: Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry 2007;164:922–928.
32.
Cottraux J, Note ID, Boutitie F, Milliery M, Genouihlac V, Yao SN, Note B, Mollard E, Bonasse F, Gaillard S, Djamoussian D, Guillard Cde M, Culem A, Gueyffier F: Cognitive therapy versus Rogerian supportive therapy in borderline personality disorder. Two-year follow-up of a controlled pilot study. Psychother Psychosom 2009;78:307–316.
33.
Hoglend P, Amlo S, Marble A, Bogwald KP, Sorbye O, Sjaastad MC, Heyerdahl O: Analysis of the patient-therapist relationship in dynamic psychotherapy: an experimental study of transference interpretations. Am J Psychiatry 2006;163:1739–1746.
34.
Hoglend P, Bogwald KP, Amlo S, Marble A, Ulberg R, Sjaastad MC, Sorbye O, Heyerdahl O, Johansson P: Transference interpretations in dynamic psychotherapy: do they really yield sustained effects? Am J Psychiatry 2008;165:763–771.
35.
Nadort M, Arntz A, Smit JH, Giesen-Bloo J, Eikelenboom M, Spinhoven P, van Asselt T, Wensing M, van Dyck R: Implementation of outpatient schema therapy for borderline personality disorder with versus without crisis support by the therapist outside office hours: a randomized trial. Behav Res Ther 2009;47:961–973.
36.
Chiesa M, Fonagy P, Holmes J, Drahorad C: Residential versus community treatment of personality disorders: a comparative study of three treatment programs. Am J Psychiatry 2004;161:1463–1470.
37.
Chiesa M, Fonagy P, Holmes J: Six-year follow-up of three treatment programs to personality disorder. J Pers Disord 2006;20:493–509.
38.
Chiesa M, Fonagy P, Gordon J: Community-based psychodynamic treatment program for severe personality disorders: clinical description and naturalistic evaluation. J Psychiatr Pract 2009;15:12–24.
39.
Arnevik E, Wilberg T, Urnes O, Johansen M, Monsen JT, Karterud S: Psychotherapy for personality disorders: short-term day hospital psychotherapy versus outpatient individual therapy – A randomized controlled study. Eur Psychiatry 2009;24:71–78.
40.
Black N: Why we need observational studies to evaluate the effectiveness of health care. BMJ 1996;312:1215–1218.
41.
Facchinetti F, Ottolini F, Fazzio M, Rigatelli M, Volpe A: Psychosocial factors associated with preterm uterine contractions. Psychother Psychosom 2007;76:391–394.
42.
Forstmeier S, Rueddel H: Improving volitional competence is crucial for the efficacy of psychosomatic therapy: a controlled clinical trial. Psychother Psychosom 2007;76:89–96.
43.
Golkaramnay V, Bauer S, Haug S, Wolf M, Kordy H: The exploration of the effectiveness of group therapy through an Internet chat as aftercare: a controlled naturalistic study. Psychother Psychosom 2007;76:219–225.
44.
Grossman P, Tiefenthaler-Gilmer U, Raysz A, Kesper U: Mindfulness training as an intervention for fibromyalgia: evidence of postintervention and 3-year follow-up benefits in well-being. Psychother Psychosom 2007;76:226–233.
45.
Vervaeke GAC, Emmelkamp PMG: Treatment selection: what do we know? Eur J Psychol Assess 1998;14:50–59.
46.
van Manen J, Kamphuis JH, Visbach G, Ziegler U, Gerritsen A, Van Rossum B, Rijnierse P, Timman R, Verheul R: How do intake clinicians use patient characteristics to select treatment for patients with personality disorders? Psychother Res 2008;18:711–718.
47.
DeJong CAJ, Derks FCH, Van Oel CJ, Rinne T: Gestructureerd interview voor de DSM-IV persoonlijkheidsstoornissen (SIDP-IV). Sint Oedenrode, Stichting Verslavingszorg Oost Brabant, 1996.
48.
Pfohl B, Blum N, Zimmerman M: Structured Interview for DSM-IV Personality (SIDP-IV). Washington, American Psychiatric Press, 1997.
49.
Livesley WJ, Jackson DN: Manual for the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ). Port Huron, Sigma Press, 2002.
50.
van Kampen D: The DAPP-BQ in The Netherlands: factor structure and relationship with basic personality dimensions. J Pers Disord 2002;16:235–254.
51.
Verheul R, Andrea H, Berghout CC, Dolan C, Busschbach JJV, Van der Kroft PJA, Bateman AW, Fonagy P: Severity Indices of Personality Problems (SIPP-118): development, factor structure, reliability and validity. Psychol Assess 2008;20:23–34.
52.
van Beek N, Verheul R: Motivation for treatment in patients with personality disorders. J Pers Disord 2008;22:89–100.
53.
Derogatis LR, Melisaratos N: The Brief Symptom Inventory: an introductory report. Psychol Med 1983;13:595–605.
54.
de Beurs E, Zitman FG: De Brief Symptom Inventory (BSI): de betrouwbaarheid en validiteit van een handzaam alternatief voor de SCL-90. Maandbl Geestelijke Volksgezond 2006;61:120–141.
55.
Derogatis LR: SCL-90-R: Administration, Scoring and Procedure. Manual-II for the Revised Version. Townson, Clinical Psychometric Research, 1986.
56.
Arrindell WA, Ettema JHM: SCL-90-R: herziene handleiding bij een multidimensionele psychopathologie-indicator. Lisse, Swets & Zeitlinger, 2003.
57.
Lambert MJ, Burlingame GM, Umphress V, Hansen NB, Vermeersch DA, Clouse GC, Yanchar SC: The reliability and validity of the outcome questionnaire. Clin Psychol Psychother 1996;3:249–258.
58.
Brooks R, Rabin R, de Charro F: The Measurement and Valuation of Health Status Using EQ-5D: A European Perspective. Evidence from the EuroQol BIOMED Research Programme. Dordrecht, Kluwer Academic Publishers, 2003.
59.
Cohen J: Statistical Power Analysis for the Behavioral Sciences. Hillsdale, Erlbaum, 1988.
60.
Rosenbaum PR, Rubin DB: The central role of the propensity score in observational studies for causal effects. Biometrika 1983;70:41–55.
61.
Imbens GW: The role of the propensity score in estimating dose response functions. Biometrika 2000;87:706–710.
62.
Bartak A, Spreeuwenberg MD, Andrea H, Busschbach JJV, Croon MA, Verheul R, Emmelkamp PMG, Stijnen T: The use of propensity score methods in psychotherapy research. A practical application. Psychother Psychosom 2009;78:26–34.
63.
Spreeuwenberg MD, Bartak A, Croon MA, Hagenaars JA, Busschbach JJV, Andrea H, Twisk J, Stijnen T: The multiple propensity score as control for bias in the comparison of more than two treatment arms: an introduction from a case study in mental health. Med Care 2010;48:166–174.
64.
Hodgson R, Bushe C, Hunter R: Measurement of long-term outcomes in observational and randomised controlled trials. Br J Psychiatry 2007;191:78–84.
65.
Chiesa M, Drahorad C, Longo S: Early termination of treatment in personality disorder treated in a psychotherapy hospital. Quantitative and qualitative study. Br J Psychiatry 2000;177:107–111.
66.
McGlashan TH: The prediction of outcome in borderline personality disorders; in McGlashan TH (ed): The Borderline: Current Empirical Research. Washington, American Psychiatric Press, 1985, pp 61–98.
67.
Plakun EM: Prediction of outcome in borderline personality disorder. J Pers Disord 1991;5:93–101.
68.
Links PS, Mitton MJE, Steiner M: Stability of borderline personality disorder. Can J Psychiatry 1993;38:255–259.
69.
Ryle A, Golynkina K: Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome. Br J Med Psychol 2000;73:197–210.
70.
Gunderson JG, Daversa MT, Grilo CM, McGlashan TH, Zanarini MC, Shea MT, Skodol AE, Yen S, Sanislow CA, Bender DS, Dyck IR, Morey LC, Stout RL: Predictors of 2-year outcome for patients with borderline personality disorder. Am J Psychiatry 2006;163:822–826.
71.
Ogrodniczuk JS, Joyce AS, Lynd LD, Piper WE, Steinberg PI, Richardson K: Predictors of premature termination of day treatment for personality disorder. Psychother Psychosom 2008;77:365–371.
72.
Chiesa M, Fonagy P: Prediction of medium-term outcome in cluster B personality disorder following residential and outpatient psychosocial treatment. Psychother Psychosom 2007;76:347–353.
73.
Bohus M, Haaf B, Simms T, Limberger MF, Schmahl C, Unckel C, Lieb K, Linehan MM: Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004;42:487–499.
74.
Kroger C, Schweiger U, Sipos V, Arnold R, Kahl KG, Schunert T, Rudolf S, Reinecker H: Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting. Behav Res Ther 2006;44:1211–1217.
75.
Fassbinder E, Rudolf S, Bussiek A, Kroger C, Arnold R, Greggersen W, Huppe M, Sipos V, Schweiger U: Effektivität der dialektischen Verhaltenstherapie bei Patienten mit Borderline-Persönlichkeitsstörung im Langzeitverlauf – Eine 30-Monats-Katamnese nach stationärer Behandlung. Psychother Psychosom Med Psychol 2007;57:161–169.
76.
Kleindienst N, Limberger MF, Schmahl C, Steil R, Ebner-Priemer UW, Bohus M: Do improvements after inpatient dialectial behavioral therapy persist in the long term? A naturalistic follow-up in patients with borderline personality disorder. J Nerv Ment Dis 2008;196:847–851.
77.
National Institute for Health and Clinical Excellence: Antisocial Personality Disorder: Treatment, Management and Prevention. London, NICE, 2009. www.nice.org.uk.
78.
National Institute for Health and Clinical Excellence: Borderline Personality Disorder: Treatment and Management. London, NICE, 2009. www.nice.org.uk.
79.
National Institute for Mental Health in England: Personality Disorder: No Longer a Diagnosis of Exclusion – Policy Implementation Guidance for the Development of Services for People with Personality Disorder. London, DoH, 2003.
80.
Bartak A, Spreeuwenberg MD, Andrea H, Holleman L, Rijnierse P, Rossum BV, Hamers EFM, Meerman AMMA, Aerts J, Busschbach JJV, Verheul R, Stijnen T, Emmelkamp PMG: Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorders: results of a large prospective multicentre study. Psychother Psychosom 2010;79:20–30.
81.
Lorentzen S, Hoglend PA: Moderators of the effects of treatment length in long-term psychodynamic group psychotherapy. Psychother Psychosom 2008;77:321–322.
82.
Digre EI, Reece J, Johnson AL, Thomas RA: Treatment response in subtypes of borderline personality disorder. Pers Ment Health 2009;3:56–67.
© 2010 S. Karger AG, Basel
2010
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.